RESHAPING CARE FOR OLDER PEOPLE Val Hatch NHS Fife, Martin Thom Social Work and Kenny Murphy Fife Voluntary Action

INTERMEDIATE CARE & SUPPORT SERVICES COMPONENT PARTS Hospital at Home Intermediate Care Home Care Intermediate Care Framework in Fife also includes Independent Sector Beds Alan McLure / Valley House Single Point of Access for hospital discharge being developed thought the discharge hub at Victoria Hospital Intermediate Care Hospital at Home Patient/Service User INTRODUCTION INTERMEDIATE CARE & SUPPORT SERVICES

HOSPITAL @ HOME Community Life Assessment & Clinical Care Patient Activity Net Budget £2.205M A community clinical assessment and care model that support people at home as an alternative to hospital admission Provision Implementation Plan DWF April 2012 KLM July 2013 GNEF Sept/Oct 2013 Total New Patients Ave LoS 5-8 days Age Criteria Adults Suitable Conditions Infection, eg. Chest, urine, cellulites Delirium Falls – no lower limb fracture Exacerbation of Chronic Disease Reduced mobility related to illness/accident Dehydration Feedback from users Positive and nearly always about being cared for at home. Investment from Change Fund £2.205M Community Life Assessment & Clinical Care Patient HOSPITAL @ HOME

INTERMEDIATE CARE TEAMS Activity A multi-disciplinary team of practitioners who prodie a period of rehabilitation ina persons home. Focussed on both prevention of admission and early supported discharge from hospital. Co-located in three areas in Fife: QMH Whyteman’s Brae Adamson Provision Approximately 600-670 new referrals each month Ave Los 21 days Age Criteria over 65’s Feedback from users No structured process to measure, however evaluation indicated a high level of satisfaction New funding provided through LUCAC £500,000 Community Care At Home Patient/Service User INTERMEDIATE CARE TEAMS

DISCHARGE HUB What we have done 2 Social Work Service Reablement Occupational Therapists, 6 NHS Fife Patient Flow Co-Cordinators and 1 Administrative Support Purpose To maintain patient flow from hospital focussing on support for discharge for frail complex patients focussing on return home. To provide quicker access to; Community rehabilitation services Homecare services Downstream and/or intermediate care bed options Reduce delays Provision Support across all hospitals in Fife Fully implemented in VHK by end December 2013 Activity In 4/5 wards approx 40 individuals per week a large number of which are going directly home. Investment LUCAC / NHS Fife £321,550 Social Work Service £84, 000 *(Area Team Link Social Workers Up to £237, 500) DISCHARGE HUB

HOME CARE System Community Service User Activity Net Budget £18M Current overspend of £3.156M Service User Developing a model to support people to live at home, as independently as possible through adopting and delivering a reablement approach across all Care at Home provision. 3000+ individual packages 1.2M hours of care at home Telecare clients 12/13 = 1,287 Community alarms 12/13 = 6,974 Community Benefits Supports safe maintenance of individuals at home and within the community for as long as possible and promotes independence and community integration. System Increased number of Home Carers, Home Care Managers, Specialist Reablement Occupational therapists and Home Care Reablement Training Staff all employed through Change Fund Investment of £2M. Telecare investment of £350,000. System Community Service User HOME CARE Customer Satisfaction Home care (November 2012) 91% satisfied Telecare (February 2013) 93% satisfied Community Alarms (February 2013) 96% satisfied

INTERMEDIATE CARE BEDS What have we done 2 local Authority Homes (14 beds) 3 Independent Sector Homes (20 beds) Service User Benefits Access to a safe and enabling environment where the focus is on improving well-being, confidence, resilience and skills improvement. That aims to return individuals to live safely within their own homes. Community Benefits Reduces unnecessary long term care placements and admission to hospital. Assists to facilitate discharge from hospital. Supports a safer re-integration home and into the community System Benefits Opportunity to provide intensive reablement within a supportive environment to build skills and resilience and allow individuals to return to live within their own homes. Allows detailed holistic assessment of skills etc. to ensure that no-one is admitted into long term care unless that is the most appropriate resource to meet their needs. Investment Change Fund £400,000 for independent sector home provision. Fife Council investment in local authority care home provision £254,436 for both Valley House and Alan McLure.* INTERMEDIATE CARE BEDS

RESHAPING CARE Investment: £70.542m   Older Peoples Social Work services provide support people to live as independently as possible within their own communities. The service has over 1590 staff members, and in addition to assessment, care management and the protection of older people at risk of harm across Fife, we provide a wide range of in-house and external services, mostly aimed at protecting individuals who are most at risk in the community. The services provided include Long Term Care placements and funding, Day and Respite care facilities, care at home services, and a number of services to prevent admission into long term care, and hospitals. The change fund is being used to change a number of these models and services, and by working in partnership we hope to continue to develop sound models that will shift the balance of care and reshape services for older people across Fife. RESHAPING CARE

LIFE LONG LIVING 11 Projects Not just “capacity building” but making real contributions to Preventative & Anticipatory Care Proactive Care & Support at Home Effective Care at Time of Transition Hospital & Care Homes Change Fund Investment £500,00